Updated 17 August 2017

Sore throat or rheumatic heart disease?

Is it just a sore throat, or an attack on your child's heart? Rheumatic heart disease is the leading cause of preventable heart disease in African children.

Just a sore throat? Or an attack on your child’s heart? This Rheumatic Heart Disease Week (5-11 August), the Heart and Stroke Foundation South Africa calls attention to a "forgotten" killer.

The term "heart disease" calls to mind a death sentence or long-term suffering. Yet there is one type of heart disease – rheumatic heart disease – that is entirely preventable; all it takes is treatment with penicillin.

According to the World Health Organisation, rheumatic heart disease, is the leading cause of heart disease in children on the African continent. Professor Bongani Mayosi, Head of Department of Medicine at University of Cape Town, calls it "the forgotten but devastating disease". Dr Jonathan Carapetis, of the Menzies School of Health Research, Darwin, Australia, reminds us that "this is the most solvable cardiac problem affecting the developing world today".

Rheumatic heart disease results from repeated bouts of acute rheumatic fever. The latter can develop after an untreated sore throat caused by Group A streptococcal (Strep A) infection. Timeous treatment of the Strep A sore throat with antibiotics can prevent rheumatic fever.

Dr. Liesl Zühlke, Paediatric Cardiologist and Doctoral Fellow of the Mayosi Research Group at the University of Cape Town, says:

“Strep A attacks the heart valves, brain, joints and skin. Although the other tissues will recover, it is the heart where permanent damage can occur. This permanent damage is known as rheumatic heart disease (RHD). RHD is serious and dramatically affects quality of life, very often requiring open-heart surgery to repair, or replace damaged valves. It can cause heart failure, severe problems during labour and childbirth for pregnant mothers and even death.”

Fewer cases of rheumatic fever are seen in developed countries and this is believed to be the result of improved living conditions and availability of antibiotics for treatment of Strep A sore throats. Conditions such as overcrowding, poor housing conditions, under-nutrition and lack of access to healthcare play a role in the persistence of rheumatic heart disease in developing countries. These challenges exist in South Africa, where a large portion of our population lives under poverty-stricken conditions which leave them disproportionately vulnerable to the disease. Sadly, the weakest and poorest of our children are at risk.

Kids between the ages of 5 and 15

Alarmingly, 60% of all acute rheumatic fever cases will develop into rheumatic heart disease. Estimated figures suggest a worldwide prevalence at least 15.6 million cases, with 282 000 new cases and between 350 000 to 500 000 deaths globally each year. However, a more recent study suggests that these figures may be underestimated, with new estimates suggesting that 62 - 78 million individuals worldwide are affected.

Children are most at risk between the ages of 5 to 15, and in areas where overcrowding is common, the disease can also develop in adults. Rheumatic fever is completely preventable by treating the Strep A sore throat with penicillin – primary prevention being an easy and cost-effective remedy. In contrast, treatment of rheumatic heart disease and valve damage is significantly more expensive, requiring surgical intervention.

People who have had a previous attack of rheumatic fever are at high risk for a recurrent attack, which worsens the damage to the heart. Prevention of recurrent attacks of acute rheumatic fever is known as secondary prevention. This involves regular administration of antibiotics, and has to be continued for many years. Secondary prevention programmes are currently thought to be more cost effective for prevention of rheumatic heart disease than primary prevention and may be the only feasible option for low- to middle-income countries in addition to poverty alleviation efforts.

Raising awareness

Surgery is often required to repair or replace heart valves in patients with severely damaged valves, the cost of which is very high and a drain on the limited health resources of poor countries. In South Africa, state health facilities are unable to carry such a costly burden, leaving many people waiting years for surgical treatment, and many more dying as a result. And as a neglected disease cases often go undiagnosed and untreated, which add to the number of people requiring heart surgery.

Acute rheumatic fever is a notifiable disease by law, which allows the authorities to keep track of cases in the country. However, Dr Mpiko Ntsekhe, a cardiologist at the Department of Medicine, Groote Schuur Hospital in Cape Town, says:

“Most doctors in South Africa neglect to report cases, leading to the false belief among health officials and other experts that rheumatic heart disease has ‘gone away’. Nothing could be further from the truth. The only excuse for the persistence of rheumatic fever and rheumatic heart disease is neglect on the part of health planners and clinicians.

“Unfortunately, the link between a sore throat and heart disease is not in the public consciousness and few people seek or get appropriate therapy. Once your child has had rheumatic fever, all is not lost. It is still possible to prevent subsequent serious heart damage by taking penicillin injections or tablets regularly to prevent recurrences of strep throat and rheumatic fever.”

Dr Vash Mungal-Singh of the Heart and Stroke Foundation South Africa stresses that if rheumatic heart disease can be controlled in the developed world there is no reason why South Africa cannot aim for the same. She says:

"There is no political or financial gain not to strive for control. The health of our children and youth is just as precious, and it does not take much other than clinical efficiency and political will. Persisting rheumatic heart disease in South Africa will surely reflect negatively on medical and political bodies."

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